- Ectopic Pregnancy
- Ovarian Cyst
- Pelvic Inflammatory Disease
- Placental Abruption
- Implantation of a fertilized ovum outside the uterusT The fallopian tube is the most common.
- Occurs in about 2% of all pregnancies and accounts for 6% of all maternal deaths.
- Vaginal bleeding, abdominal/pelvic pain, adnexal mass, amenorrhea
- Rupture of ectopic pregnancy can cause hypotension, syncope, and peritonitis
- Beta HCG > 1500, but no signs of intrauterine pregnancy on transvaginal ultrasound.
- If beta-hCG levels rise, but do not double over the course of 48 hours, then it is likely an ectopic pregnancy.
- Resuscitate, give RhoGAM to Rh ( -) women, consult OB/GYN
- Methotrexate (unless contraindicated). Surgery may be needed.
*Deep Dive: Ectopic Pregnancy (SAEM)
- Endometriosis is the presence of endometrial tissue implanted outside the uterus (pelvic cavity, uterine ligament, bowel, lungs, ovaries, etc.)
- Most common site is the ovaries
- “Three D’s” (dyspareunia, dyschezia, dysmenorrhea)
- Often presents asymptomatically or with pelvic pain before/during menses
- Laparoscopy and biopsy required for definitive diagnosis
- Analgesics (NSAIDS)
- Hormone therapy (danazol, oral contraceptives, progestins, GnRH agonists, aromatase inhibitors)
*Deep Dive: Endometriosis (Merck Manual)
- Fluid-filled sac within the ovary. Generally benign, but can lead to torsion, rupture, hemorrhage, or infection.
- Follicular cysts are the most common; other types include corpus luteum cysts (can cause rapid bleeding) and Theca lutein cysts (seen in pregnancy)
- Most are asymptomatic; common symptoms include lower abdominal pain, bloating, and dyspareunia.
- If ruptured, can cause significant pain, hypotension, tachycardia
- Transvaginal ultrasound
- Masses > 5 cm concerning for ovarian torsion
- Most cysts < 5cm resolve on their own. Provide NSAIDs for analgesia
- Surgery required for complicated cysts
*Deep Dive: Benign Ovarian Masses (Merck Manual)
Pelvic Inflammatory Disease
- Acute, bacterial infection that ascends from cervix/vagina to the upper genital tract (uterus, fallopian tubes, ovaries, and adjacent structures)
- Most commonly caused by Chlamydia trachomatis
- Lower abdominal pain, fever, vaginal discharge/bleeding
- (+) “Chandelier sign” (cervical motion tenderness), (+) mucopurulent cervicitis
- Clinical diagnosis
- Must have tenderness (abdominal, uterine, adnexal, or cervical) + one more criteria (fever, discharge, elevated ESR/CRP, documented GC/Chlamydia infection)
- Antibiotics (ex. ceftriaxone + doxycycline +/- metronidazole)
- Treat infected partners
*Deep Dive: Pelvic Inflammatory Disease (WikEM)
- Hemorrhage caused by premature separation (partial or full) of implanted placenta from the uterine wall after 20 weeks gestation.
- Often associated with trauma; most common cause of third trimester bleeding
- Painful vaginal bleeding is the most common sign, but may not always be present.
- May have tender uterus and signs of shock
- Clinical diagnosis
- Ultrasound may help identify retroplacental bleeding
- Stabilize (ABC’s, blood products, RhoGAM). Consult OB/GYN emergently
- Definitive treatment is delivery of the fetus/placenta.
*Deep Dive: Placental Abruption (emDOCs)